Dr. Kelly Powers and Julie Pagel will be presenting this work at the American Association of Critical Care Nurses (AANC) National Teaching Institute (NTI) in May 2019. The presentation is entitled: Cultivating Clinical Reasoning: Nurse Preceptor Role in New Graduate Nurses' Transition to Practice
Transitioning to the role of professional nurse can be both an exciting and stressful time for new graduates. Prelicensure nursing education does not typically provide courses focused on critical care as students are being prepared for generalist practice; therefore, new graduate nurses who enter into critical care settings where specialized knowledge is needed can experience pronounced stress.1 This stress not only can result in new graduate intent to leave their position but also can impair patient safety.2 To help ensure a positive transition and safe nursing practice, it is crucial for new graduate nurses to receive support and continued education with an emphasis on enhancing their clinical reasoning.2 Nurse preceptors work closely with new graduates during their orientation, which uniquely positions them to provide this support and education. This article discusses the literature on transition to practice (TTP), with a focus on the challenges faced by new graduates who begin their careers in critical care. Also discussed is the vital role preceptors play in enhancing new graduate nurses' clinical reasoning abilities.
NEW GRADUATE NURSES' TTP
New Graduate Nurses
After completing their prelicensure education and passing the National Council Licensure Examination (NCLEX), new graduate nurses are hired to work in health care facilities on a variety of general and specialty units. In 2017, more than 160 000 newly educated nurses successfully passed the NCLEX in the United States to enter professional nursing practice.3 The great majority of newly licensed nurses (82.2%) reported working in acute care hospitals, with critical care units being the second most commonly reported practice setting.3 In fact, 23.3% of newly licensed nurses in the United States reported working in a critical care setting in 2017, which had increased from 18.7% in 2014.4 Because of a sustained nursing workforce shortage and an older and more complex patient population, there will continue to be a demand for new graduate nurses in specialty areas such as critical care.5
Although almost one-fourth of new nurses work in critical care settings immediately after graduating, a recent review of the literature found that orientation to this specialty area greatly varies.1 Overall, new graduate orientation varies depending upon facility and specialty area, with 2017 figures indicating that, across practice settings, the range for orientation length was approximately 3 to 13 weeks, with an average of 9.8 weeks spent working with an assigned preceptor.4 Specific to critical care, it has been found that orientation length, content, and implementation vary significantly for new critical care nurses and there is a lack of research focused on new graduate nurses' TTP in this specialty area.1 More research is needed to formulate specific recommendations for critical care nursing orientation; however, the studies conducted to date indicate that nurse preceptors have a vital role in assisting new graduate nurses to transition to critical care practice.1
Transition to Practice
The period when new graduates move from the role of student nurse to the role of professional nurse is known as the TTP period. It has been identified as a time of reality shock6 and transition shock7 as novice nurses learn about the many aspects of their new role. Transition shock occurs when the new graduate recognizes the differences between his/her known role as student nurse and the less familiar role of the practicing nurse, with differences noted for relationships, responsibilities, and knowledge and performance expectations.7,8 In nursing school, students learn about various disease processes and the associated nursing care, and they have opportunities to apply this knowledge while caring for actual patients in clinical settings. However, there are challenges inherent in clinical education that often prohibit students from gaining a full understanding of, and experience with, all the components of the professional nurse role. Some of the challenges include high student-to-faculty ratios, repeatedly moving from one clinical site to another, and a lack of clinical sites to gain essential experiences.9 In an effort to ensure patient safety when nursing faculty are overseeing a large number of students (who may not be very familiar with the patient population or site-specific policies, equipment, medication and documentation systems, etc), staff nurses and faculty often assign students to care for just 1 patient who is in stable condition.10 Then, when they begin their careers, new graduate nurses often have to immediately manage care for multiple complex patients while also learning to organize their day-to-day responsibilities,11,12 which include documentation, answering calls, working with family members and the interprofessional team, and advocating for their patients. Thus, the sheltered student role of providing care to one stable patient is quite different from what a practicing nurse actually does during each work day. This leads to transition shock, often accompanied by feelings of anxiety and incompetence, as new nurses are faced with the realities of their practice.7,8
Research has repeatedly shown that the TTP period is very stressful for new graduate nurses.8,13,14 Transitioning from student nurse to practicing nurse on a critical care unit can add another dimension of stress as most nursing programs focus on preparation of the generalist nurse as is dictated by the American Association of Colleges of Nursing “Essentials of Baccalaureate Education.”15 This means that most nursing programs do not specifically prepare students for critical care specialty areas,5 resulting in about one-fourth of new graduates who transition into a specialty area where they likely lack experience. To improve new graduate nurses' TTP experience in all practice settings, it is vital to narrow the academia-practice gap so the contrast between the roles of student nurse and practicing nurse is less pronounced. To bridge the gap from academia to practice, the Institute of Medicine called for the implementation of TTP, or nurse residency, programs for all new graduate nurses to provide continued opportunities to apply important knowledge to patient care and gain further practice experience.16
Hospitals have also recognized a need to focus more on the TTP period, and cost implications are a driving force. Approximately 25% of new graduate nurses leave their position within the first year of practice,2 and this results in a considerable cost burden for hospitals. It has been estimated that the cost to replace 1 new graduate nurse is between $49 000 and $92 000,17 with more recent cost estimates for nurse turnover as high as $96 000.18 Turnover also negatively impacts patient outcomes and is associated with poorer quality of care including increased use of restraints, development of pressure ulcers, and patient falls.19 In addition to a need to reduce turnover, there is also a need to focus on the TTP period to improve the care provided by new graduate nurses. In a survey of 5700 nurse leaders, only 10% felt new graduates are fully prepared to provide safe, effective care.20 Research shows new graduates report more negative safety practices and more errors than experienced nurses.2 With advances in technology and higher patient acuity, nurses must provide increasingly complex care, and there is a need for interventions to better prepare new graduates to safely and effectively care for patients.16
In response to evidence demonstrating that the TTP period is associated with negative outcomes, the National Council of State Boards of Nursing (NCSBN) conducted a large, multisite study that enrolled 1088 new graduate nurses from 105 hospitals in 3 states.21 On the basis of their hospital work site, new graduates were randomized into a control or intervention group. Hospitals that were part of the control group implemented their usual orientation process, whereas hospitals that were part of the intervention group adopted the NCSBN's TTP program for new graduate nurses. The NCSBN TTP program included 6 months of working with a trained nurse preceptor who was “educated in their role through an online training module.”21(p25) New graduates also completed modules based on the Quality and Safety Education for Nurses competencies of patient-centered care, communication and teamwork, evidence-based practice, quality improvement, and informatics. In addition, patient safety and clinical reasoning were threaded through each of these modules. An additional 6 months of institutional support was then provided. Results showed that the turnover rate in the NCSBN TTP program was 14.7%, whereas hospitals that did not have a structured curriculum experienced a turnover rate of 25%.21 In addition, hospitals that used the NCSBN TTP program and those hospitals in the control group that already had a structured orientation program in place had fewer reported negative safety practices by new graduates at 6, 9, and 12 months.21 Researchers concluded that TTP programs for new graduate nurses should be formalized, be at least 6 months long, include a focus on clinical reasoning, and use preceptors.21
NEED TO ENHANCE CLINICAL REASONING
Importance of Clinical Reasoning
Clinical reasoning is “the ability to reason as a clinical situation changes, taking into account the context and concerns of the patient and family.”9(p85) It is the process by which nurses make judgments about patient care, and this includes generating alternatives, weighing them against the evidence, and choosing the most appropriate action.22 Thus, clinical reasoning involves both clinical judgments and clinical decision making.23 Furthermore, nurses' clinical reasoning is based upon both knowledge and experiences, and expert nurses evaluate patient data to “find patterns and generate hypotheses based on their accumulated experience.”24(p76) The development of one's ability to clinically reason occurs over time,24-26 and this development is essential for safe nursing practice.23,27 As patient acuity and complexity continue to rise and the health care environment becomes increasingly fast-paced, there is a need to focus on promoting clinical reasoning development so new nurses are able to make sound decisions in practice.24,26
New Graduate Nurses' Clinical Reasoning
Clinical reasoning assists the experienced nurse in judging clinical situations to determine the need to intervene when a patient is deteriorating. Recognizing patient deterioration and concluding the proper intervention are challenges that many novice nurses face when new to clinical practice, especially in the time frame shortly after orientation.10,26 In the critical care unit, the subtle changes in patient condition, recognized intuitively by the experienced nurse, are often missed by the new graduate. “Failure to rescue” is the term used in the literature to describe this type of situation. It is the unsuccessful detection of a worsening patient condition due to a complication from illness or from medical care.28 In essence, failure to rescue occurs when the signs of patient deterioration are unrecognized or are acted upon too late or not at all.26 For new nurses, this often occurs because of difficulty in differentiating between patient issues that require immediate attention and those that are less acute or when there is a large amount of data to process during time-sensitive situations.23 As new graduate nurses gain experience and their clinical reasoning develops, their ability to detect and act upon patient deterioration to provide safe care evolves as well.
Clinical reasoning is emphasized in prelicensure nursing programs to provide a foundation for making safe patient care decisions; however, novice nurses do not have the experience to back up the knowledge they have learned in nursing school.29,30 Continuing education postgraduation is essential to enhance new graduate nurses' clinical reasoning and ability to recognize and prevent failure to rescue.29,30 A deliberate focus on clinical reasoning during orientation is important because failure to rescue is directly related to nurses' clinical reasoning abilities.23 However, orientation is most often focused on review of policies and procedures, preceptor-supervised care of patients, and completion of checklists to denote satisfactory performance of tasks and competency assessments (such as psychomotor skills).31 Although these orientation components are important, there is also a need to emphasize development of clinical reasoning as recommended by the NCSBN.2,21
In critical care units, patients are unstable and at a high risk for complications, making it vital for close clinical surveillance by nurses to ensure patient safety.32 This surveillance is necessary to detect changes in patient condition and to make decisions regarding these changes. A higher level of clinical surveillance and decision making is required in critical care than other settings because of the higher level of patient acuity and potential for rapid deterioration.32 Because research has shown that critical care nurses anticipate patient problems by relying upon their past experiences of a similar context,32 it is of crucial importance to focus on developing clinical reasoning in new graduate nurses who lack previous experience with caring for critically ill, unstable patients.
IMPORTANCE OF NURSE PRECEPTORS
Importance of Nurse Preceptor Role
New graduate nurses have indicated that preceptors are vital in helping to bridge the gap between academia and practice, increasing their knowledge, and socializing them to the role of the nurse and to becoming a part of their unit's culture and team.33,34 New graduates also report that nurse preceptors play an important role in building their confidence and lessening their anxiety, which enables them to become more independent and to assume a full workload over time.33,34 Indeed, it has been repeatedly found that nurse preceptors are instrumental in helping new graduates transition effectively into nursing practice.33 Specific to critical care settings, nurse preceptors are “seen as a significant resource” to new graduates who value their knowledge and teaching, as well as their guidance and support.1(p64)
Although new graduate nurses have passed their licensure examination, they are not at the same level of experienced nurses and need structured clinical supervision during their TTP period.35 Nurse preceptors have a vital role in assisting new graduates to transition safely and effectively into professional practice, and the preceptor role is vast. First, the primary duty of the preceptor is to ensure that patient safety is upheld while the new graduate nurse gains clinical knowledge and experience. To assist new graduates to successfully TTP, preceptors help them learn hospital and unit-specific policies and procedures, perform psychomotor skills that may have been learned but rarely practiced in school, use equipment and documentation systems that may be unfamiliar, create and implement plans of care as they manage their time while progressively assuming a full patient assignment, and become socialized to the unit's culture and health care team. Although these role aspects are familiar to the nurse preceptor, often, they represent new experiences for the novice nurse. Therefore, an essential part of precepting new graduates is identifying the occurrence of reality and transition shock and using support and teaching strategies to help build their confidence and ability to practice safely.1
In critical care settings, the preceptor role can be even more challenging because most new graduate nurses have had little or no previous education specific to critical care.5 Policies and guidelines, psychomotor skills, equipment, and plans of care that are inherent to this setting will likely then represent large amounts of new knowledge and new experiences. In addition, new graduates typically do not have previous experience with caring for unstable patients.10 Yet, in critical care, there can be a constant need to adjust plans of care as acuity changes, and this is accompanied by a need to collaborate with multiple members of the interprofessional team to provide this complex care. Furthermore, there are also often difficult situations, such as providing end-of-life care (to include care of the family), that new graduates may not have previously been exposed to. Essentially, new graduate nurses do not have previous experiences to rely upon in the fast-paced and dynamic critical care environment where care is complex and the need for split-second decisions often arises. Furthermore, the ever-changing patient conditions do not allow novice nurses much time to analyze the situation and formulate and weigh options for care. For this reason, critical care nurse preceptors must remain especially vigilant in regard to ensuring patient safety while deliberately concentrating on promoting new graduates' clinical reasoning. If clinical reasoning is not a deliberate emphasis, overwhelmed new graduate nurses are more likely to be focused on tasks and just getting through the day, which can result in following orders without asserting clinical judgment.10
Preceptor Role in Enhancing Clinical Reasoning
Nurse preceptors work closely with new graduates during orientation, and this relationship provides the preceptor with frequent, ongoing opportunities to work on developing clinical reasoning abilities. Throughout orientation, preceptors have a key role in ensuring that clinical reasoning and the ability to recognize when and how to respond to a change in patient condition are a priority focus. In fact, skilled nurse preceptors are considered crucial to the successful transition of new graduate nurses because they can role model their own clinical reasoning.31 It is, however, important to then mention that, to role model and encourage clinical reasoning, nurse preceptors must have gained enough practice experience to possess solid clinical reasoning skills themselves.
There are many ways in which nurse preceptors can help develop new graduates' ability to clinically reason. First, it is pivotal for ongoing and deliberate formative assessment to occur to be able to provide feedback and direction about further improvement needs.36 Therefore, discussions, debriefings, and reflection are important strategies that help preceptors to understand a new graduate nurse's thinking and reasoning, to coach him/her through formulating and weighing patient care options, and to exchange feedback to promote continued growth.36 It is also important for preceptors to frequently ask open-ended questions to encourage deeper thinking, a wider view of the patient situation, consideration of alternative options, and linkage to previous experiences.31,36,37 Other common strategies used by preceptors include providing examples from one's own previous experiences, building on past learning, encouraging dialogue both in the moment and reflectively, role modeling actions and thinking (using think-aloud), and providing practice with clinical scenarios via case studies, role play, and simulations.24,25,31,36,37
Although the literature details strategies that preceptors can use to enhance new graduate nurses' clinical reasoning, it is important to note that, although nurse preceptors are often considered expert clinicians, this does not necessarily mean that they are expert teachers.37 Because teaching is a vital part of precepting, being an effective nurse preceptor “requires pedagogical competence and skills.”38(p1) In addition to receiving training on orientation timelines and role responsibilities, preceptors should also be educated on adult learning theory, learning styles, and effective teaching and feedback strategies.5,8,21 Yet, despite the literature repeatedly stressing the importance of preceptor education,1,5,8,21,37 nurse preceptors often report that they do not feel prepared for their role and lack confidence in their ability to teach new graduate nurses.31,38 Research shows preceptors want training to be able to better educate new graduates who are transitioning to practice, and they specifically want education on ways to promote clinical reasoning.31 This has important implications for nurse educators and managers. It is essential for education on strategies to promote clinical reasoning to become an integral part of nurse preceptors' role preparation.8,36,37 Furthermore, including an experiential component in this education would be invaluable to allow preceptors the practice they need to become effective coaches of clinical reasoning. Although significant efforts have been made to better the TTP period for new graduate nurses, more focus on preparation of nurse preceptors would ultimately further improve the TTP experience and new graduates' ability to provide safe patient care.
There is a need to focus on improving new graduate nurses' transition into professional practice and their clinical reasoning abilities, with both concepts intertwined. Nurse preceptors play a pivotal role in facilitating a successful TTP because they work closely with new graduates for an extended period. This provides countless opportunities to work on developing clinical reasoning to ensure the ability to provide safe and effective care with increasing confidence. For those new graduate nurses who begin their careers in critical care, the necessity of focusing on clinical reasoning development is even more pronounced. It is imperative that nurse preceptors be educated on their crucial role, and this education must have a deliberate emphasis on preparing preceptors to use evidence-based strategies for improving new graduate nurses' clinical reasoning abilities.
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